A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?

Place new linen on the client's bed every other day.

Change gloves between sites when providing wound care to multiple wounds.

Change the dressing on infected wounds first.

Monitor vital signs every 4 hr.

Answer and Explanation

The Correct Answer is B

A. Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection.

B. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures.

C. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique.

D. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.

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Correct Answer is C

Explanation

A. "There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.": This statement demonstrates the mother's comprehension of the cause of strabismus, which can indeed result from a muscle imbalance affecting the alignment of the eyes. Understanding the cause is essential for the mother to grasp the rationale behind treatment interventions.

B. "I will have my child wear an eye patch over the good eye to help strengthen the weak eye.": Patching the stronger eye is a common treatment approach for strabismus to encourage the weaker eye to become stronger and improve alignment. The mother's statement indicates her awareness of this treatment modality.

C. "My child will outgrow this by the time he is 2 years old and be able to see just fine.": While some cases of strabismus may improve as a child grows, not all cases resolve spontaneously. This statement suggests the mother's belief in the possibility of spontaneous resolution, which may be accurate in some instances but not guaranteed for all cases of strabismus.

D. "If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.": Surgery is indeed an option for correcting strabismus, especially if conservative measures like patching do not yield satisfactory results. The mother's understanding of this potential treatment escalation reflects her grasp of the condition's management plan.

A. Maintain seizure precautions. B. Document intake and output. C. Administer antibiotics when available. D. Reduce environmental stimuli.

Correct Answer is C

Explanation

A. Maintain seizure precautions:

While seizures can occur as a complication of bacterial meningitis, maintaining seizure precautions is not the nurse's priority at this stage. Prompt administration of antibiotics to address the underlying infection takes precedence over seizure precautions.

B. Document intake and output:

Documenting intake and output is an important nursing responsibility, but it is not the priority when a child is suspected of having bacterial meningitis. The immediate priority is to initiate antibiotic therapy to treat the infection and prevent further complications.

C. Administer antibiotics when available:

Administering antibiotics is the priority in the care of a child with suspected bacterial meningitis. Antibiotics are crucial for treating the infection and preventing its progression to reduce the risk of serious complications such as brain damage or death.

D. Reduce environmental stimuli:

While reducing environmental stimuli can help manage symptoms and discomfort in a child with bacterial meningitis, it is not the priority at this time. Initiating antibiotic therapy is essential to address the underlying infection, which takes precedence over environmental stimuli reduction.

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A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?

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